Transfusion Therapy
and Safety
Mary Grabowski, RN, BSN, BSIA
Transfusion Safety Officer
PSONEC Fundamentals – March, 2015
Blood Component Therapy
• Blood Components
• Special Processing/Attributes
– Irradiation
– Leukoreduction
– CMV Negative/CMV Safe
• Patient Safety
– Type and Crossmatch Verification
– Unit Verification
– Monitoring
– Transfusion Reactions
Composition of Blood
~55-60% Plasma
~40-45% Formed Elements
• Red Blood Cells (RBC)
• Leukocytes (WBC)
• Platelets
• Reference Information
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Coagulation
Cryoprecipitate = Fibrinogen
Components - Whole Blood Donation
RBC
Platelet
Plasma
Apheresis Donation
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Platelets
Plasma
RBCs
Granulocytes
Pooled for adults
(5 units pooled in
one bag)
Cryoprecipitate
Pool for adults
(5 units pooled in
one bag)
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Platelets – Standard Adult Dose
• Pooled Platelet
• From whole blood donors
• 5 units in pool
- or -
• Apheresis Platelet
• From apheresis donor
• Lab will issue one of the
above depending on
availability
Red Blood Cells
Indications
• Symptomatic anemia
• Severe bleeding
• General Guidelines:
Hgb/Hct
<7 / 21%: RBC likely required
7-10 / 21-30%: Varies with clinical condition
>10 / 30%: RBC unlikely required
Red Blood Cells
Therapeutic Effect
• Average size Adult (per unit)
–  Hgb ~ 1 gm/dL
=
 Hct ~ 3%
• Dose: number of units given depends on
clinical situation
ONE and DONE!
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Platelets – Indications
• Prevent bleeding r/t bone marrow failure:
– <10,000/l
• Active bleeding or surgery:
– <50,000/l
• general med/surg patients
Platelets
Therapeutic Effect
• Platelets
–  ~ 30,000/l per bag
– <100,000/l :
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massive hemorrhage
severe vascular injury
diffuse alveolar hemorrhage
eye surgery
neurosurgery
Plasma Indications
• INR > 1.5 with one of the following:
Plasma
Therapeutic Effect
• Adult: One unit:
–  most coagulation factors ~ 2.5%
– Active bleeding
– Urgent invasive procedure required
• Dose based on clinical condition and
underlying disease process
– Adult dose: 10-15mL/kg
• Usually 3-6 units
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Cryoprecipitate
Indications
• Hypofibrinogenemia
– Fibrinogen < 100 mg/dL
– Or < 150 mg/dl – if expected to fall significantly
• Disseminated Intravascular Coagulation
• Active bleeding
Cryoprecipitate
Therapeutic Effect
• 1 Pool (5 units/pool):
–  fibrinogen ~ 37 mg/dL
• Adult Dose:
– 1 - 2 units per 10kg (1 or 2 Pools)
Granulocytes
Therapeutic Effect
Granulocytes - Indications
• Preparation
– Collected by apheresis machine
– Always Irradiated
• Indications - Severe neutropenia with:
– Life-threatening bacterial or fungal infection
• not responsive to antimicrobial therapy
• May or may not see increase in WBC count
• Dose
– Pediatrics: max 20mL/kg/day
– Adults: 1 unit/day
– Neonates with sepsis
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Irradiation
Applicable Components
Irradiation Process
• HOW
RBC
Platelets
– Placed in Irradiator
• EFFECT- Inactivates
Lymphocytes
WBCs
WBCs
– Prevents replication and
ability to attack the
recipient’s tissue
Note: Granulocytes - ALWAYS IRRADIATED
Irradiation - Purpose
• Prevent
– Transfusion-Associated Graft versus Host Disease
• Similar to GVHD seen in BM/Stem Cell transplant
recipients
• Immunocompromised patients do not destroy
the infused lymphocytes in the blood component
– Lymphocytes engraft / proliferate
– Attack host tissue
Transfusion-Associated Graft Versus Host
Disease
• Lymphocytes launch attack against
– Skin, Liver, Gut
– Bone Marrow
• Clinical symptoms present
8-12 days post-transfusion
– Fever
– Skin - skin rash
– Liver - elevated LFTs, hepatitis
– Gut - diarrhea, anorexia, nausea/vomiting
– Bone Marrow - bone marrow failure (pancytopenia)
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Transfusion-Associated Graft Versus
Host Disease - Outcome
• Outcome: ~ 90 % mortality
– Infectious complications
– Bleeding complications
– Death typically occurs 3-4 weeks post-transfusion
Transfusion-Associated Graft Versus
Host Disease
• Patients with competent immune systems at risk
for TA-GVHD
– * Components from blood relatives
• No longer offered by Bloodworks NW
• No effective treatment
– * HLA matched platelets
• Prevention is a must!
* ALWAYS irradiate above components for ALL patients
Irradiation Indications
Leukoreduction Process
• HOW
See Handout for Specifics
– Pass component through
Leukoreduction filter at PSBC
– Apheresis machine during collection
• Effect
– Majority of the leukocytes removed
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Leukocyte Reduction
Applicable Components
RBC
Leukoreduction – Purpose
• Reduce unwanted effects caused by WBCs and
their by-products released during storage
Platelets
– Prevent Febrile Non-Hemolytic Transfusion Reactions
WBCs
WBCs
– Prevent Alloimmunization
PSBC
100% Leukoreduction of RBCs and Platelets
– Use as substitute for CMV negative components
Note: Granulocytes are NEVER Leukoreduced
Leukoreduction
• Prevent recurrent:
– Febrile Nonhemolytic Transfusion Reaction
• Cause – not completely understood
– Antibody mediated
Leukoreduction
• Help prevent:
– Alloimmune Platelet Refractoriness
• Alloimmunization
– Development of patient antibodies against donor HLA
antigens
• Patient antibodies react with infused WBCs
– WBCs breakdown during storage
• Cytokines released into the component
• WBCs contain human leukocyte antigens (HLA)
• 30-50 % of multitransfused patients develop HLA
antibodies
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HLA Antibody Development – 2 to 4 weeks later
Multiple Non-Leukoreduced Transfusions
Recipient antiHLA antibody
HLA
Class I
HLA Class II
HLA
Class I
HLA Class II
HLA Class I
Donor White Blood Cell
Donor White Blood Cell
Alloimmune Platelet Refractoriness
Multiple antibodies to
different HLA
antigens via multiple
transfusions with
non-LR products
Donor
Platelet
Alloimmune Platelet Refractoriness
• Poor platelet count increment ~ < 5,000
– At 1 hour post transfusion
– On at least 2 occasions
Anti- HLA- A5
HLA - A5
Transfused Platelet
Premature
removal by
the spleen
No increase in
platelet count
• Obtain platelets counts
– Pre-transfusion
– 1 hour post (10-60 min)
• PSBC do workup
– Patient – HLA antibodies
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HLA Matched Platelets
• Donor’s HLA typing
– Matched to patient’s HLA typing (HLA A, B)
– As much as possible
• Apheresis - collect from matched donor
Leukocyte Reduction
• Reduce rate of HLA alloimmunization in organ
transplant patients/candidates
– Renal
– Heart
– Lung
• Initial order often requires 48 hours notice
• Resource limited by donor pool
Leukoreduction
• Creates CMV “Safe” Component
• Help prevent CMV transmission
• Risk of transplant rejection due to HLA
antibodies
CMV
(Cytomegalovirus)
• Herpes virus
• CMV lies dormant in tissues and circulating
leukocytes of infected individuals
• ~ 50 % of population in WA is CMV positive
• Poses little problems to those with competent
immune systems
– Most have no history of illness
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CMV Neg/Safe Components
CMV Safe Components
• CMV transmission– reduced by use of either:
• Purpose
– Prevent primary CMV infection in
immunocompromised CMV-negative patients
• Serious complications
– CMV-associated pneumonia, myocarditis, retinitis,
hepatitis, gastroenteritis
CMV Safe Indications
– CMV Negative Components
– Leukoreduced Components
• With 100% Leukocyte Reduction
– Many facilities discontinued CMV Neg ordering option
– LR substituted for CMV Neg
Critical Points in Transfusion Process!
1) Collection and labeling of
Type/Cross/Screen sample
See Handout for Specifics
• “Wrong Blood In Tube” can be fatal!
• Two person verification at bedside
2) Pre-Transfusion Verification
• Transfusing wrong unit can be fatal!
• Two person verification at bedside
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2 Person Verification at Bedside
(Type/Cross, Type/Screen, Hold, 2nd Sample)
Type and Crossmatch Sample
1. If able, ask patient to state name/DOB and compare to armband
2. At bedside, check that Name and MRN on all three sources
match exactly:
1. ARMBAND
2. PATIENT LABEL
3. REQUEST FORM
• Required – Red Blood Cells
– Sample in last 3 days
Test, Jane D.
MRN: 01234567
BD: 1/1/1950
Must Match
• Not required – platelets, plasma, or cryo
– If pt’s blood type (ABO/Rh) on file at Bloodworks NW
2nd Confirmatory ABO/Rh Sample
• If pt has no prior hx of blood type (ABO/Rh) at PSBC
– 2nd separately collected sample is required before routine RBCs
will be issued
Transfusion Administration
• Purpose – Increased Safety!
– Double check blood type
– Prevent Wrong Blood in Tube errors – which can be fatal
• Must be drawn at later (different) time than 1st sample
• Not required: Platelet, Plasma, or Cryo orders
• 1st sample – send immediately
• 2nd sample – send ASAP
– Emergency RBC units will not be
delayed due to lack of 2nd Sample
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Pre-Transfusion Preparation
Pre-Transfusion Preparation
(continued)
1. Verify Consent
2. Verify IV access: 20 gauge or
larger preferred, but not required
3. IV Pump – use for all components
4. Blood Tubing Y-Set (with filter)
– 0.9% NS only
– Prime with NS, saturate filter, fill drip chamber 1/3 full
– Never use other IV solutions
– Never add medications
– Limit – 4 units or 4 hours (whichever 1st)
– Exception – use new set for Platelets
Component Pick-up from Lab
Component Handling
• Take a copy of EMR Pick-Up Slip to Lab
• Never place a RBC or Plasma unit in refrigerator on
nursing inpatient unit
– Units may be stored in Blood Bank Refrigerator only
• Downtime
► Copy of paper Order
• Emergency when neither available
► Patient chart label
Test, Jane D.
MRN: 01234567
BD: 1/1/1950
• Perform double check with
Lab and sign log
• Platelets and Cryoprecipitate must always remain at
room temperature
– Must never be placed in any refrigerator or cooler
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2 Person BEDSIDE CHECK
Transfusion Report
(tag attached to blood bag)
• Informed Consent
• Check component against MD’s order
• Involve patient, ask patient to state name and birth date, verify against
armband
• Compare items shown below, must be identical
• Compare patient’s blood type on trans tag with unit type to ensure they are
compatible
• Check compatibility testing date/time, if performed
• Visual Inspection
• Check boxes - sign tag
Trans Tag
Name
MRN
Name
MRN
Unit #
Blood Type
Expiration
Unit #
Blood Type
Expiration
Monitoring – All Products
Blood Tags
Check 3 boxes
Two signatures
with date / time
of verification
Never discard
Place in patient’s
paper chart
Blood Bag Label
1. Start within 30 minutes of Lab issue
– Return to Lab < 30 min, if cannot
Maria Lee, RN
John Thomas, RN
01/04/07
1220
01/04/07
1220
2. Transfusion Assessment
(T, RR, HR, BP, SaO2, lung & skin assessments)
– Pre, 15 minutes, End
– 1 hour post
– Any time reaction is suspected
3. Stay with patient - first 15 minutes
4. Reaction Assessment q 30 minutes
5. Complete within 4 hours of issue from Lab or before
expiration (if sooner)
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Transfusion Rates – Routine Non-Emergent
(Adults)
• First 15 minutes (non-emergent):
– Start slowly: 25 ml over 15 min = 100 ml/hour
• After 15 minutes:
– If no reaction, increase to rate on Transfuse Order
– Rate guidelines (non-emergent transfusions):
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Red cells: 1.5 - 4 hours
Platelets: 1 hour
Plasma: 30 - 60 min
Cryoprecipitate: 15 - 30 min
Acute Transfusion Reactions
Stop and do not restart:
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Transfusion Reactions – Signs/Symptoms
Anxiety
Hypotension/Shock
Hypertension
Fever (>1 oC or 1.8 oF)
Chills (with or without fever)
Pain - Back, Chest, IV
Dyspnea
Tachycardia
Hemoglobinuria
Oliguria / Anuria
Hives
Itching
Cough
Nausea
Vomiting
Abdominal cramps
Headache
Cyanosis
Diaphoresis
Generalized bleeding
Reaction Job Aid
Febrile Nonhemolytic
Acute Hemolytic
Transfusion Related Acute Lung Injury
Anaphylactic
Bacterial Contamination
Volume Overload
With Provider order, may restart:
• Urticarial (Mild Allergic) only
– Stop
– Antihistamine (Benadryl)
– If reaction resolve, restart slowly
– Observe q 15 min
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Possible Reaction - Steps
Reaction Workup – Submit to VMC Lab
1) STOP TRANSFUSION
2) Notify Provider (RRT/Code prn)
Bag and attached
tubing/IV solution
3) Monitor vital signs and symptoms
4) Check tag against armband and bag label to verify right
unit was given to right patient
5) Hang new IV set with new 0.9% NS bag to keep line
1 or 2 Lavender or pink tops
open (TKO). Do not flush or use blood set.
6) Treat symptoms per Provider’s orders
7) Send workup to hospital lab
Call Lab to obtain pink Reaction form
Reference Information
Next Fresh Urine
Sample (if red/dark)
10 Ways to Help Ensure Safest Transfusion Possible for
Your Patient
1. 2 Person Verification at Bedside - Blood Bank Samples
2. 2 Person Verification at Bedside - Pre-Transfusion
– Special Attributes Indications Sheet
– Transfusion Reaction Algorithm
– Other guides at BloodworksNW.org
3. 0.9% NS only to prime blood tubing set
4. Begin transfusion slowly first 15 minutes = 100 ml/hour
5. Monitor patient before, during, and after transfusion
6. Ensure rate of infusion is appropriate for your patient
7. Finish within 4 hrs of Lab issue (or before expiration, if sooner)
8. Change blood tubing set every 4 units or 4 hrs (whichever first)
– Always use new set for Platelets
9. Know how to recognize and treat reactions
10.Report reactions to Provider and submit workup to VMC Lab
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Resources
• Institution’s Policies
• Bloodworks NW website
– http://www.BloodworksNW.org
• Transfusion Safety Officer, Mary Grabowski
Pager 206-969-5222
[email protected]
• Bloodworks NW, Central Seattle Lab
– (206) 292-6525, #3
– Request On-Call Physician as needed
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